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Name: Declan Murphy Word count: 2998

Global Health: What Does it Mean for ENT?

Introduction

Global health is a term to describe the conduction of transnational research to identify variables that

influence health, and the use of information gathered to inform evidence-based decisions which aim

to improve health across the world.(1)

In 2007, the World Health Organisation (WHO) outlined the main threats to global human health in

the 21st Century.(2) These include a rise in epidemic-prone diseases, foodborne diseases, accidental or

deliberate outbreaks of infectious disease, toxic chemicals and radionuclear materials, and finally

environmental disasters which influence health through multiple avenues.(2)

An acute threat to global health is climate change.(3,4) Research demonstrates its direct and indirect

influence on health. The greatest effect on health will arise from limited access to safe food and water,

and dirtier air. Climate change is estimated to contribute to an additional 12.6 million death each

year.(5)

Otorhinolaryngology and Global health

Ear, Nose and Throat (ENT) surgery, also called Otorhinolaryngology, is the surgical specialty

concerned with the diagnosis, evaluation and management of head, neck, ear, nose and throat

diseases.(6) ENT encompasses a vast disease spectrum, much of which is treatable through

manoeuvres and medical management but equally, surgical intervention is often indicated.

ENT disease prevalence, risk factors and treatment vary between developed and developing countries.

Health provision, particularly surgery, in developing countries is poor and their healthcare systems are

unstable.(7) Technological advances provide ENT surgery with novel diagnostic and treatment

opportunities, however new technology is inaccessible to developing countries which further

contributes to the great difference in ENT practice between the developed and developing world.(2,8)

The American Academy of Otolaryngology has outlined the main ENT diseases requiring intervention

in low- and middle-income countries (LMIC). These include thyroid and parathyroid disease, hearing

loss, chronic ear disease, tracheostomy care and paediatric airway pathologies.(8)

In this essay, I will outline key global health concerns in otorhinolaryngology, discuss why

discrepancies in ENT services between developed and developing countries exist, provide an insight

into future challenges for global otorhinolaryngology, and finally suggest methods to minimise ENT’s

global burden.

Hearing Loss

In 2012 it was estimated that 5.3% of the world’s population were living with disabling hearing loss

(DHL), defined as a hearing impairment greater than 40db when 15years or older, or greater than

30dB when younger than 15years.(9) The burden of hearing loss predominates in LMICs, particularly

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Sub-Saharan Africa (SSA), south Asia, and the Asian pacific.(9) The prevalence of hearing loss decreases

exponentially as gross national income (GNI) increases, both for adults and children.(10)(figure 1) 48%

of adults over 65years in south Asia have DHL, compared with 18% of those from high-income

countries (HIC).(10,11)

Figure 1: The prevalence of Disabling hearing loss (<15yrs) decreases as GNI increases.(11)

Why does hearing loss matter?

Whether from a developed or underdeveloped country, chronic hearing loss in children impairs

speech and language development.(12) Disability and handicap results, for example through poor

educational and vocational attainment. Unemployment rates are higher in deaf adults, and those that

do achieve employment, usually receive a lower grade than the general population.(12) Children whose

hearing is impaired are more prone to experiencing emotional, sexual and physical abuse, including

murder.(12,13)

WHO estimates that unaddressed hearing loss has a global cost of 750 billion international dollars.(10)

Many causes of DHL are preventable and owing to its negative consequences, prevention is

paramount.

Hearing loss in developing countries

The prevalence of childhood DHL is higher in developing countries. 2.4% of children under 15 years of

age have DHL in South Asia, a low-income country, compared with 0.5% in HICs.(11) 80% of the world’s

deaf population receive no education, particularly skewed towards LMICs where almost all deaf

people don’t, causing devastating consequences for deaf childrens’ futures.(14)

Causes of hearing loss in children and adolescents

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60% of DHL in children under 15yrs is preventable with a disproportionately high burden in LMICs

where 75% are preventable, compared with 49% in HICs.(10)

Infections are the main preventable cause.(15) They occur antenatally (rubella and syphilis) or during

infancy (mumps, measles and rubella). Persistent middle ear infections cause chronic suppurative

otitis media (CSOM), a condition affecting 330 million people worldwide. It is more common in LMICs,

accounting for roughly 25% of the ENT workload, where it is associated with higher complication rates

too.(10,15–17) Secondly, complications from childbirth may cause sensorineural hearing loss, usually

secondary to cerebral damage, which may result from birth asphyxia and hyperbilirubinaemia;

complications more commonly affect premature neonates.(10) Finally, ototoxicity is the third main

cause, most commonly arising from medication use in babies or pregnant mothers.(10)

Figure 2: Disabling hearing loss in adults 65yrs+.(11)

Hearing loss in adults

Although the proportional difference between LMICs’ and developed countries’ DHL prevalence is

largest in those under 15yrs old, adult populations differ too.(figure 2) Adult DHL is usually due to

disease originating from childhood, degenerative changes, and noise-induced DHL.

Noise-induced hearing loss is particularly prevalent in LMICs. Many LMICs are experiencing rapid

urbanisation and therefore increased noise exposure with minimal regulation.(18) Residents and

workers are exposed to high noise levels which contributes to the high prevalence of noise-induced

DHL.(12)

How can we minimise preventable causes of hearing loss in LMICs?

As many DHL cases in LMICs are preventable, we can intervene in various ways to reduce its incidence.

Self- and herd-immunity can be induced through providing childhood immunisations, particularly

against measles, mumps, rubella and bacterial meningitis.(10,12) Contraceptive access in LMICs is poor.

Therefore immunising women of reproductive age against rubella, screening pregnant females for

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syphilis, and improving antenatal care all help reduce neonatal DHL.(10,12) HIV prevention would reduce

its influence on CSOM complication rates (OR 4.3, 95% CI; 1.17–15.6; p=0.028).(17) Implementing

newborn hearing screening programmes in LMICs would improve the early diagnosis and treatment

of sensorineural hearing loss. High quality ENT training for professionals, accessible primary health

care services, and up-to-date technology could prevent unsafe prescribing of ototoxic medication and

would allow disease to be identified at an early stage. Early disease identification would reduce the

prevalence of CSOM-associated complications that occur at an increased rate in prolonged and

untreated disease (OR 1.03, 95% CI; 1.007–1.05; p=0.01).(17)

Minimising noise exposure is essential. In the UK, The Control of Noise at Work Regulations 2005

ensures that employers reduce occupational noise to prevent it impairing their employees’ hearing.(19)

Pressure must be put on LMIC governments to create similar legislation, which often is lacking. If

environments and occupations cannot be altered, personal protective equipment must be available.

LMICs carry a larger proportion of DHL than developed countries but care is minute in

comparison.(20,21) Although small, progress has been made over the last decade, particularly primary

care health service expansion in LMICs with a focus on educating local people in the effective

management of ear diseases.(20–22)

Disease of the Nose, Pharynx and Larynx

A prospective cohort study assessed the burden of ENT disease in LMICs. Roughly 2600 patients were

assessed and followed-up for three years, all of whom presented to secondary care outpatient

departments and healthcare camps in an Indian farming community with high poverty rates.(21) All

diagnoses were made by trained professionals who decided whether ENT referral was indicated.

Roughly 8% had a nasal disorder, 50% attributable to acute rhinitis, likely due to working in masonry,

with paint, and around dust.(21)(figure 3) Seasonality showed an increasing incidence in winter.

8% had recurrent sinusitis, becoming chronic in all patients after three years or less.(21) Nasal polyposis

requiring surgery affected 10% of patients.(21)

19% of those with swallowing difficulty or hoarseness had chronic laryngitis and tonsillitis caused 49%

of throat pain.(21) Iron deficiency is epidemic in many LMICs due to diet, worm infections, malaria and

poor antenatal care.(23) As a result, Plummer Vinson’s syndrome - a triad of iron deficiency, atrophic

glossitis and oesophageal webs or strictures - was diagnosed in 23% of those with swallowing

difficulty.(21)

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Figure 3: Nasal diseases in Vellore District of Tamil Nadu.(21)

Air pollution and LMICs

Air pollution is the contamination of any environment by substances (chemical, biological or physical)

that modify its natural characteristics.(24) With in-depth knowledge of the adverse impacts of air

pollution, developed countries have made successful efforts to reduce levels.(25) This is not the case in

LMICs. As industry has expanded, air pollution has remained high, and efforts have either minimally

reduced levels or they have remained static.(25)

Previous research has demonstrated a positive correlation between disease incidence and air

pollution concentrations. Respiratory and cardiovascular diseases particularly are associated, with

morbidity and mortality rates increasing.(25) NO2 and SO2, affect the upper airway and middle ear

causing inflammation, irritation and infection.(26,27) Higher levels of air pollution is associated with

increased incidence of head and neck cancer, which is discussed later.(28,29)

A study in Beijing evaluated the influence of air pollution on otolaryngology outpatient attendance.(27)

NO2 and SO2 concentrations showed positive associations with outpatient attendance.(27) Exposure to

air pollution early in life increases the risk to both upper and lower respiratory tract infections in

children, including middle ear infection.(30,31) Exposure to a combination of pollutants accelerates the

onset of allergic rhinitis, particularly inducing exacerbations.(27) These findings are consistent with

other studies.(30–32)

Data on air pollution’s influence on ENT disease is limited. Higher air pollutant concentrations in

developing countries may suggest that LMICs suffer greater air pollution associated ENT disease

burden than HICs. Further research is required for confirmation.

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Head and Neck Cancer

Head and neck cancers (HNC) are the sixth most common cancer worldwide.(33) Two thirds of the

global burden of HNCs occur in LMICs, and the Indian subcontinent alone is responsible for one third

of lip and oral cavity cancers.(29)

The incidence of HNCs is increasing globally, particularly among women, likely due to increased alcohol

and tobacco use, and improved diagnostic capabilities.(29,34) Alcohol and tobacco use remain the

greatest risk factors for laryngeal cancer. Tobacco primarily influences disease at the vocal cords and

glottis, and alcohol mainly in the supraglottic region. Synergism is evident between HNC risk factors,

particularly tobacco use (smoking and smokeless), Gutka chewing as it contains Areca nut, alcohol

consumption, and oral Human papillomavirus (HPV) infections.(35)

Smoking

Over the last 10yrs tobacco use has been increasing by 2-3% per year in India, and is expected to be

responsible for 13% of all deaths there by 2020.(36) In LMICs, cancer of the oral cavity and throat is one

of the commonest causes of death; the Aizawl district has the highest incidence of pharyngeal and

tongue cancer in the world, 11.5/100,000 and 7.6/100,000 respectively.(33)

Alcohol

In most LMICs, alcohol is consumed infrequently but heavily.(37) Moderate and heavy alcohol use

increases the risk to cancers, including cancer of the larynx, with a systematic review demonstrating a

risk-ratio of 1.44 (95% CI 1.25–1.66) for moderate consumption and 2.65 (95% CI 2.19–3.19) for heavy

consumption.(37,38) Through lack of education, LMIC inhabitants are less aware of alcohol’s negative

consequences and alcohol cessation strategies tend to fail.(37)

Air pollution and HNC

High levels of air pollution is associated with an increased risk to developing HNC.(28) 74% of the Indian

population relies on solid fuels, greatly contrasting that of HICs, where in April 2017 Britain generated

all electricity without using any coal.(39) India is using increasing quantities of coal, rising at a rate of

2.8% each year.(28,40)

A retrospective case-control study investigated how exposure to air pollution from solid fuels affects

the incidence of laryngeal and hypopharyngeal cancer.(28) Exposure to burning coal indoors for over

50yrs increased the risk of developing hypopharyngeal (OR 3.47, CI 0.95–12.69) and laryngeal (OR

3.65, CI 1.11–11.93) cancers.(28) Other solid fuels such as wood increased the risk to hypopharyngeal

cancer too (OR 1.62, CI 1.14–2.32) but not in never-smokers.(28)

Human Papillomavirus (HPV) and HNC

HPV is present in 50% of Squamous cell carcinomas (SCC) of the head and neck, particularly affecting

the tongue and tonsils.(33) Changing oral sexual practices and the presence of high-risk HPV genotypes

increase the frequency of HPV-associated HNCs in LMICs. These particularly affect younger patients

and aren’t sex-specific.(33) HPV is present in 16% of oral and laryngeal cancers in HICs; this is fewer than

in LMICs, especially India where prevalence ranges from 33.6% to 67%.(41)

By understanding the biology of HPV-associated cancers, there is no reason to suggest that the HPV

vaccine’s protective properties would differ in efficacy between HNC and anogenital cancer.(42) HPV

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vaccinations for genotypes 16 and 18 could prevent over 90% of HPV-associated oropharyngeal

cancers, supporting the argument that males should be vaccinated too, owing to their higher risk for

HPV-associated HNC.(42,43)

HPV vaccines are widely available in high-income and some middle-income countries. Although one

of the most-cost effective methods for disease prevention, vaccines are rarely available in low-income

countries.(44,45) For vaccines to become widely available, substantial financial subsidies must be

provided. Recently, Ministries of Health and non-governmental organisations (NGO) have used

donated vaccinations to try and improve conditions.(44) Although a good effort, governmental and

international projects are essential otherwise HPV-associated HNC rates are unlikely to fall.

HNC care improvements in the developing world

Steps must be taken to both prevent and manage HNC in LMICs. Primary preventative initiatives such

as international media campaigns to raise awareness of the current HNC crisis, taxing tobacco and

alcohol use, designating smoke-free areas, vaccinations, ventilation for buildings, and safe-sex

programmes are essential. Secondary prevention by appropriately training professionals to manage

HNCs and encouraging smoking cessation would help too.

Climate change and ENT

With the beginning of the industrial revolution, humans have released gases into the lower

atmosphere that trap energy and contribute to global warming by amplifying the Earth’s natural

greenhouse effect.(46) As the Earth continues to warm our climate changes, and its effect on human

life and health already is evident.

Climate change has been referred to as one of the greatest risks to human health, and between 2030

and 2050 is predicted to cause around 250000 deaths per year.(47) Figure 4 outlines how climate

change affects human health.

Climate change’s health impact will be felt across the globe, most prominently however, in LMICs.

LMICs already have weak health infrastructures, particularly for ENT services, and damage for example

through loss of land and overcrowding, will impair its ability to cope.(47) Changes in air pollution and

aeroallergen concentrations will affect otorhinolaryngeal disease, and changes in the distribution of

vector organisms will predispose to infectious disease, including those of the nasopharynx, ear, and

paediatric airway.(3,46,48)

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Figure 4: Diagrammatic depiction of the mechanisms through which climate change can affect human

health.(46)

How can we improve ENT Global Health for the future?

The ENT disease burden predominates in developing countries, unfortunately being a prime example

of the inverse care law in action. Although not to the same extent as in developed countries, the

population in LMICs is ageing. Along with ageing comes an increased disease burden, increasing

demands on health services, rationing of treatment, and longer waiting times. Although interventions

such as an ENT training programme established in SSA showed promise, there was minimal

improvement in the population’s ENT health as the community’s population grew at a rate that

overwhelmed new services after just six years.(49) It seems that improved education and

communication, humanitarian efforts, and introducing self-sustaining healthcare infrastructures are

necessary approaches to reduce the global burden of ENT diseases.

Education and communication

Both public and staff in LMICs are insufficiently educated in the prevention, diagnosis, treatment, and

rehabilitation of ENT disease. Public behaviours increase the population’s risk to disease and health

care is of insufficient quality and quantity.(50) This is due to poor local training and the migration of

professionals.(50) Therefore, LMICs become dependent on the importation of external practitioners

who they cannot afford.(50) International bodies must help to fund training programmes for local

people, as done rather successfully in Malawi by Mulwafu et al.(22) Being trained to deliver

preventative healthcare, such as vaccinations and contraception, is essential.

Innovative low-cost methods for training are needed. Clark et al(51) developed an ear trainer for low-

resource settings which recently has been validated as a realistic representation of the ear for

microsurgical training. GoogleGlass is a company that has streamed live surgical operations online

using a camera attached to spectacles.(52) In 2014, its first operation was live-streamed to 13000

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surgical students from 115 different countries. Students had their questions answered by the surgeon

in real-time, representing a cornerstone in transnational education and providing promise for future

training in LMICs.(53)

Telemedicine, the use of electronic information and technology to provide healthcare when distance

separates the patient from the professional, should be utilised as an affordable way to communicate

with, and provide care to, LMICs which often have limited transport opportunities.(54,55)

Humanitarian efforts

Although most aid is provided vertically, when trying to establish a sustainable healthcare system,

horizontal aid should predominate.(56) Financial cooperation from multiple bodies is required to

establish a sustainable healthcare system in LMICs. Independent donors, universities, ministries, and

both governmental and NGOs must contribute so healthcare professionals can be recruited and

resources made available.(57)

Healthcare infrastructure

A sustainable health system requires robust financing, a well-trained workforce who are paid

appropriately, an evidence-base to assist in decision-making, technology sufficient to diagnose and

treat disease, and a system to deliver medicine and technology to patients.(50) Most LMIC’s healthcare

systems underachieve in all of these categories for various reasons.(50)

Healthcare systems operate in numerous ways. To maximise the population’s health for the lowest

cost, most funding should target high-quality primary care service provision with a focus on disease

prevention.(58) This is difficult to implement however as privately-run services often provide treatment

for established disease and thus prevention strategies are of little interest. The role of NGOs is not

simply to ‘fill gaps’ in health care; they can provide large-scale innovative health programmes.(59) NGOs

face challenges. They are dependent on donors, often lack a strategic plan and often have conflicting

political governance. Governments are often focused on short-term public popularity with short-term

objectives. Along with other political motives such as pressure from big businesses (pharmaceutical,

tobacco and alcohol), convincing governments to prioritise the long-term commitment towards

establishing an effective disease prevention strategy is challenging.

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